Editorial independence is crucial for the viability of a journal and editors have many masters - the public, the readers, the authors and the owners. Negotiating the resultant minefield requires a purposeful and independent stance. This is particularly so in instances of a relatively modern phenomenon: concerted attempts by clinical groups to influence, or even abort, publication of articles, which may threaten their practice. Moreover, modern social media facilitates this manipulation.

During my tenure as the Editor of the Medical Journal of Australia (1995-2011) I was often asked the seemingly innocuous and unremarkable question: "What is it like to be an editor?". After due reflection my answer to this polite inquiry was simple: " To be an Editor is to live dangerously!"

To those professionals working outside medical publishing, such a claim may well appear an over-reach or even delusional, especially when compared with the more traditionally challenging worlds of surgery, clinical medicine and psychiatry. After all, how could one possibly claim that shuffling research papers, letters and clinical updates through the editorial merry-go-round be inherently dangerous?

But the claim does have a certain resonance for those involved in medical publishing. We immediately recall the relatively recent sacking or 'resignations' of the editors of three of the world's leading medical journals: George Lundberg of the Journal of the American Medical Association in 1999 (Smith, 1999 [12] ), Jerrome Kassirer of the New England Journal of Medicine in the same year (Smith, 1999[13]) and John Hoey and Anna-Marie Todkill of the Canadian Medical Journal in 2006 (Hoey, 2006 [7] ).

Editors of medical journals serve many masters - the public, the readers, the authors and the owners. (Marcovitch, 2008 [11] ) Negotiating this minefield of potential tension and conflict requires a purposeful and independent stance. All were sacked or resigned because of irreconcilable differences with their owners - national or state medical organizations such as- The American Medical Association, The Canadian Medical Association and The Massachusetts Medical Society.

Such abrupt terminations of employment are no less painful than any other industrial or commercial sacking, simply because they happen to occur in the somewhat removed and arcane world of medical publishing. Despite these ructions, the three Journals in question immersed themselves in the busyness of their business, continued to meet pressing publication deadlines and life moved inexorably on. Nonetheless, the very public humiliation suffered by these editors was personally scarifying. And the notoriety of their sackings certainly adds substance to the notion: medical editors do indeed "live dangerously."

What is the Purpose of a Medical Journal?

In view of the above, it might well be asked: What is the purpose of a medical Journal? Any response is certain to be underpinned by the principle that science is not science unless it is published. To put it more pragmatically, journals exist: to inform, to interpret, to confirm, to criticise, to reform, and lastly, to amuse.

In pursuit of this quest it is pertinent to ask: "Who does an editor serve?" Marcia Angell, a Senior Editor of the New England Journal of Medicine, answers this unambiguously, stating that editors serve many masters - the public, the readers, the authors and the owners. She is also of the belief that this complex array of competing interests is a minefield of potential tensions for editors. (Angell, 1991 [1] )

For their part, editors are empowered to implement an individualised mission, unique to the journal and its readership. They are responsible for journal content from cover to cover, as well as the implementation and oversight of the crucial peer review process.

Threaded through the more mundane aspects of an editor's daily tasks is the ongoing expectation that decisions regarding suitability for publication are sound and defensible: it is the editor who is ultimately accountable for both quality and accuracy. All articles chosen for publication must meet the highest possible standards of evidence-based medicine, especially when airing controversial issues.

In keeping with this ethical standard, editors must ensure that their decisions are predominantly based on the validity of the work and its importance to readers, not the policies or commercial success of the owner, or any other vested interest. It is absolutely essential that editors be free to publish critical but responsible views without fear of retribution - even if these views happen to be at odds with the policies or commercial goals of the owner.

Ideally, editors should examine and even challenge any tendency toward the phenomena of 'confirmation bias' and 'group-think', so characteristic of institutionalised thinking. Such thinking only serves to stultify debate. In order to overcome competing considerations, Ian Douglas-Wilson, a previous editor of the Lancet, provided the counsel that: "An editor should aim to please himself; if he does not, he will certainly please no one". (Fox, 1991 [6] )

Some editors are even more provocative in defining their role. Richard Smith, past Editor of the British Medical Journal has boldly proclaimed that a good editor should: "Stir up, prompt debate, upset people, legitimise and set agendas" (personal communication; reproduced with permission). This is best achieved by aligning the journal with a cause, holding profound and informed convictions, fostering a strong editorial team and assembling a confident and experienced advisory board.

Controversial Issues Abound

In view of this, an Editor can arouse strong, and at times, vehement debate. This is inevitable in any ethnically pluralist society such as we have in Australia, where traditions, values and beliefs are essentially relative. Controversial issues abound and can stir up a veritable hornet's nest, such as: the quality and safety of medical practice, abortion, circumcision and euthanasia. And, interestingly, these issues invariably provoke a deluge of Letters to the Editor.

Indeed, there were three particular articles published during my tenure as Editor of the MJA, which excited palpable anger and a heated exchange between groups, whose convictions were diametrically opposed. The first was the quality of practice in Australian hospitals published in 1995. The statistics documented were chilling: 16% of admissions in our hospitals were associated with an adverse event causing disability or prolonged hospital stay; 51% were considered preventable; 77% resolved in 12 months; in 13% the disability was permanent; and 4.9% of patients died. (Wilson et al.,1995 [15] )

A similar study of Australian General Practice published in 1998 caused a similar furore. This was a study monitoring adverse incidents in which 805 incidents had been recorded, of which 76% were preventable and 21% had the potential for serious harm. (Bhasale et al.,1998 [3] )

Finally, there was the 1997 publication of a frank exposé of end-of-life decisions by Australian doctors, which occasioned openly hostile criticism of editorial policy. This paper revealed that euthanasia occurred in 1.8% of deaths. Among the various findings cited were statistics, which many readers found confronting, such as: the end of patients' life occurred with concurrent explicit requests in 3.5% of patients; withholding or withdrawing potentially life-saving procedures in 28.6%; and lastly, that in 30% of all Australian deaths, a medical end-of-life decision was made with the explicit intention of ending the patient's life (Kushe et al.,1997 [10] )

Two other memorable publications that generated bitter animosity and heated exchange were related to current clinical practice. The first was a commissioned editorial, (Buchbinder et al.,2009 [4] ) which commented on the timing of vertebroplasty for painful osteoporotic vertebral fractures, following the publication of two relevant randomized trials in the NEJM (Buchbinder

et al.,2009, [5] Kallmes et al.,2009 [8] ). The solicited editorial even occasioned a visit by a representative of aggrieved practitioners of vertebroplasty, demanding that the editorial not be published, as in their opinion, the NEJM articles were flawed.

The other controversial study researched the outcomes of planned homebirths in the state of South Australia. (Kennare et al.,2010 [9] ) This also provoked irate telephone calls and emails from domiciliary midwifes, even before the article had been published. The protestors demanded the article, which showed an increase in adverse events with homebirth, be withdrawn, if not rejected outright. Even the blogosphere went viral with vitriolic, partisan rants against the MJA for unapologetically going public with the unadorned statistics. In this largely uncensored forum, ad hominem attacks abound- living dangerously indeed!

Serious Lessons to be Learned

There are serious lessons to be learned from confrontations such as these. Firstly, one quickly discovers that many sincerely held convictions advanced as 'truths', are frequently opinions dressed up as facts. Ideally, a civil society allows its citizens to speak their minds on all sensitive issues, even when there is disagreement amongst the stakeholders. To seek to shut down debate is to destroy this most essential of freedoms, and everyone loses.

Secondly, given the multiplicity of forums now available in which to express an opinion, there is an inherent danger in an uncritical acceptance of what appears to be fair and reasonable comment. However, ascertaining the reliability of comment is fraught with difficulty, as the modern media is all too adept at 'massaging' a message, and at self-promotion. In medical matters simply sifting through the sheer volume of claims and counter-claims is a monumental task. And in a 'time-poor' society much goes uncorrected, trapping the unwary reader.

Thirdly, it is all too easy to criticise. Editors are constantly alert to studies, which challenge the status quo, and understand that criticism may well be warranted. But critical analysis should always be based on facts and levelled at the ways in which interpretation and meaning are shaped by the evidence. Above all, it is imperative that the presentation of verifiable data, which brings about a paradigm shift in knowledge and understanding, must be published by any self-respecting journal. (Van Der Weyden, 2010 [14] ) And yet, to embark on such a mission and challenge current custom and practice is to invite opprobrium - both personal and professional.

Despite public censure of our editorial policy in publishing the above articles, they were to become critical milestones in making the MJA an authentic medical journal - one, which mirrored the very real tensions in everyday medical practice in Australia.

During my time as Editor, we sought to make the MJA our country's premier general medical Journal - which it is: to have a strong international standing - which it does; and to establish a strong national profile in mass media outlets - which it has achieved. But none of this would have been possible without a multi-talented editorial team of devoted professionals, endowed with well-honed critical faculties and a genuine commitment to the pursuit of excellence.

At the outset, editors understand that they will be subjected to a myriad of pressures, including those from the journal's owners, whether these be commercial publishers or professional organisations. The account above reflects extraordinary prepublication pressure exerted by interested parties to modify or even abort publication of articles that could impact on their current clinical practice.

When looking back over the years, I must confess to learning a fundamental truth of medical publishing - a truth so neatly encapsulated in the advice of Ernest Hart of the BMJ:

An editor needs and must have many enemies; he cannot do without them. Woe be unto the journalist of whom all men say good things. (Bartrip,1990 [2] ).

In short, living dangerously.

Take home message

Editors are exposed to a wide range of opinions as to what should and should not be published. Sadly, their decision making is sometimes exposed to undue pressure by advocacy groups seeking to censor publication. Their campaigns are well orchestrated, targeting those whose decisions they question with flurries of anonymous emails and utilising the relatively unfettered access of social media to prosecute their case. Ultimately, these campaigns are directed directly at the editor. But the frequency of such advocacy and attempted censorship is not known. What is known, however, is that much personal angst is experienced by those caught up in the pursuit of truth - authors, peer reviewers and editors. Despite this, editors should be unafraid of pubically communicating their experiences of attempts to interefere with editorial independence and integrity.

Conflict of interest

None declared.

Declaration

This article is a substantially revised version of the original published in medicSA (a periodical of the AMA South Australia) in November/December 2010. It is reproduced with permission.

Questions that this Paper Raises

How common is pressure by clinical groups or other vested interests on editors?

What motivation underpins such activity?

Is such pressure unique to general medical journals?

Should an international repository be created to record instances of editorial manipulation by pressure groups?

Should existing professional bodies such as the ICMJE and WAME have a supervisory role in the collection, analysis and appropriate communication of these data to editors?

Dr Van Der Weyden is Emeritus Editor of the Medical Journal of Australia. He was editor from 1995-2010. Prior to this he was Professor of Haematology and Associate Professor of Medicine at Monash University Melbourne, Victoria. He is currently a member of the executive of the World Association of Medical Editors [WAME].